Daisys Dilema

[Aidey]

Right, I get it was secondary to an MI. I just take issue with the semantics of it.

As for what will happen, she will develop a tamponade eventually.

 

[Veneficus]

Right, I get it was secondary to an MI. I just take issue with the semantics of it.

As for what will happen, she will develop a tamponade eventually.

Faster still when you add water and antiplatelet aggregates to the mix.

 

[zzyzx]

Doesn't myocardial rupture occur a long time (days?) after an MI; due to the rupture of scar tissue that has formed after an MI has damaged a portion of the myocaridum? Why then are we still seeing ST elevation?

Correct me if I'm wrong; I've never researched this.

 

[Veneficus]

Doesn't myocardial rupture occur a long time (days?) after an MI; due to the rupture of scar tissue that has formed after an MI has damaged a portion of the myocaridum? Why then are we still seeing ST elevation?

Correct me if I'm wrong; I've never researched this.

The normal occurance is usually 1-10 days with the average of 4 for the reasons you described, but there can be an acute rupture usually when the conditions listed above are met.

 

[Outbac1]

Hmmmm, interesting. This still appears to me to be an MI and needs appropriate treatment. There is no indication of chest trauma. The vitals given do not include a diastolic value so no map, narrowing pressures etc can be infered. I'm not a fan of blindly dumping in copious quantities of fluid into people. Few need it. In this case she received a liter with some improvement. But it indicates a leak somewhere. Be it a myocardiac rupture or a disecting AAA isn't going to change field tx. She still needs some fluids and transport. A field pericardiocentesis isn't going to happen nor is a CT or echocardiogram.
Treat what you can and transport to the Docs and fancy epuipment.
Always good to think deeper than what you see, even if you can't treat it.

 

[Veneficus]

Hmmmm, interesting. This still appears to me to be an MI and needs appropriate treatment. There is no indication of chest trauma. The vitals given do not include a diastolic value so no map, narrowing pressures etc can be infered. I'm not a fan of blindly dumping in copious quantities of fluid into people. Few need it. In this case she received a liter with some improvement. But it indicates a leak somewhere. Be it a myocardiac rupture or a disecting AAA isn't going to change field tx. She still needs some fluids and transport. A field pericardiocentesis isn't going to happen nor is a CT or echocardiogram.
Treat what you can and transport to the Docs and fancy epuipment.
Always good to think deeper than what you see, even if you can't treat it.

I think the important thing to consider is not to start initiating any therapy that would increase bleeding.

In order for this lady to survive I would be willing to bet she is going to need cardio surgery. PCI might take a bit too long.

By understanding the pathology and deeper understanding, it should definately help your treatment decisions in the field.

Strictly going by ACS protocol this lady might find herself getting all manner of iatrogenic treatment trying to follow an algorythm or normalizing numbers.

 

[Outbac1]

Certainly something to consider, but difficult to dx in the field. So to broaden mine and others knowledge on this, how many times have you run across this in the field? In this scenario what was it that tipped you off? How would you have TX this pt if you suspected this myocardium rupture?

Thanks

 

[usafmedic45]

How would you have tx this pt if you suspected this myocardium rupture?

As quickly as possible to somewhere with CT surgery capability.

 

[Veneficus]

Certainly something to consider, but difficult to dx in the field. So to broaden mine and others knowledge on this, how many times have you run across this in the field?

In the field, never that I knew. But probably not because it didn't happen, but because I wasn't born with my current level of knowledge. If somebody might have mentioned this kind of stuff earlier in my career, I would have been better prepared.

I have seen it a handful of times in the hospital.

In this scenario what was it that tipped you off? How would you have TX this pt if you suspected this myocardium rupture?

I discussed the scenario with the author prior but I will do a walk through.

 

[Veneficus]

The most important aspect of finding a dx or complications is knowing what they might be. Earlier in the discussion I posted the 11 complications of an MI. If you never covered them, your educators have failed you.

I have a very significant interest in physical diagnosis, I wish more people outside of Europe shared such a passion. Especially EMS providers who don't have all kinds of data gathering technology. (which often is not required anyway)

It's a very hot day and you are called to an elderly lady who has had a "spell" while tending to her flowers.

Elderly, involved in physical activity in a strenuous environment. This is very ripe for a cardiac event or a ruptured aneurysm

She was removing some weeds and her husband took them down to the mulch pile on the tractor, when he came back she was collapsed on the ground. They are on a country property about an hour by road to the nearest hospital.

The patient relates she felt dizzy then had back, jaw and neck pain then crushing heavy chest pain;

In both aortic aneurysm and myocardial aneurysm or rupture, the initial pain is worse than the constant pain, in this case probably great enough to make her pass out, but either way the loss of circulation acute enough to cause neuro deficit. So the blood is either blocked, not transferring oxygen, or leaking.

When her husband found her he was not sure if she was breathing and said it looked like she was dead.

Obvious shock state, the only question is what kind? (accepting 1 or more can be present together)

She has no cardiac or medical history apart from taking oral antihypocglycaemics for diabetes.

"3. Myocardial rupture Not often seen, but usually seen in females, over 60, with no prior history of MI, history of hypertension, and no evidence of left ventricular hypertrophy.(mitral or aortic murmers) Most often seen in Anterior transmural infarcts. (STEMI) 90% to the free wall, 10% to the ventricular septum."

this is the textbook example of the risk factors for acute myocardial rupture. If you don't know your pathology though, how would you know to look for it?

BP 80 systolic
HR 48

This could point to aneurysm, cardiogenic shock, right sided MI, CVA, hypoglycemia, PE, or cardiac rupture with what we have so far. The BP is still high for typical right sided MI.

RR 8, shallow and laboured
SPO2 97% on 10lpm

Late shock state, doesn't help with differential

BGL 5mmol (about 85 mg/dl)
GCS 13 (3/4/6)

Diabetic emergency ruled out, still inadequate cerebral perfusion of profound shock.

Pain described as heavy, central chest pain 7/10
Anterioseptal infarct on 12 lead with ST elevation in V1-4
Underlying ECG is a sinus rhythm

Doesn't get more typical for an Anterior MI.

Pt meets qualifications for MI and complication of myocardial rupture.

Underlying Sinus further excludes the possibility of right sided MI with lack of compromise of sinus node.

Gray appearance, lack of perfusion to brain, suggestive of hypovolemic shock. Consider places for blood loss. Assess heart tones.

No murmers, rubs, or gallops mentioned, tamponade happens over time, consider baseline volume and reasess in a few minutes.

Consider QRS amplitude, diminished amplitude sensitive, but not specific for tamponade. But many other things point to MI with textbook complication. Significant clinical probability has been established. This complication is also the most life threatening. So if you are going to make a bet prehospital, most lethal and most evidence for. Can't be faulted for that.

Intensive Care (ALS) are coming towards you and will locate in approx 15 minutes, HEMS are avaliable but will take about 20 minutes to land at a local sportsground and its an hour (in good traffic) up the interstate to hospital.

If you had a bullet hole in your heart, you'd be looking for a surgeon. Mechanism of the hole insignificant. ALS rendezvous insignificant. ASA is out, fluid out, pressors not useful, survival will be determined by fixing the hole, not by respiratory support or correcting blood pressure numbers. Anyone not bringing blood to the party isn't contributing.

1) How do you manage this patient, and

No ASA, no fluid, no waiting, call helo, advise them of likely Dx. Start some IVs TKO, support ventilation.

2) What is wrong with them?

they have a hole in their heart.

If it looks like a duck, walks like a duck, and quacks like a duck, until proven otherwise, it is a duck.

 

[zzyzx]

Veneficus wrote "If it looks like a duck, walks like a duck, and quacks like a duck, until proven otherwise, it is a duck."

Weren't we talking about zebras? I very much admire your assessment skills, but you'd have to be awfully sure of your abilities to make this diagnosis based on just a history and exam.

All the same, thanks for a very interesting and education scenario!

 

[Veneficus]

Veneficus wrote "If it looks like a duck, walks like a duck, and quacks like a duck, until proven otherwise, it is a duck."

Weren't we talking about zebras? I very much admire your assessment skills, but you'd have to be awfully sure of your abilities to make this diagnosis based on just a history and exam.

All the same, thanks for a very interesting and education scenario!

I am not bad at my exam skills

Really though, the education here places a premium on it, students here don't make it out of the 4th year if they cannot dx where in the brain an acute stroke is from history and physical as an example.

 

[MrBrown]

...students here don't make it out of the 4th year if they cannot dx where in the brain an acute stroke is from history and physical as an example.

A CT scan is part of a physical exam right?

*Brown and Oz stand by the helicopter with a CT machine next to it and scratch thier head

Dang it Oz, don't think this thing will fit, lets try it one more time! .....

 

[zzyzx]

Here's what Brown and Vene dream of when they go to sleep...

http://fineartamerica.com/featured/unicorn-zebra-marjorie-peterson.html

 

[Veneficus]

A CT scan is part of a physical exam right? .....

Only in the US.

Everywhere else it is an adjunct to the physical exam.

A junc t?

A junk?

 

[Outbac1]

Thanks

Mr. Brown & Veneficus thanks for a good scenario with detailed explanations. That was a good reminder to look beyond the obvious for other problems/complications. Too often we just treat what is initially presenting without digging deeper like we should.

Thanks

 

[mycrofft]

"Paraneoplasticsyndrome"

Brown, auscultation of thorax and abdomen, preferably fore and aft please. (Et tu, Bruit?).

PS: USAF, I was only taught about being drenched with carbamates. Where's that pesky Atropen and 2-PAM autoinjector when you need them?

 

[mycrofft]

disregard

anomaly in posting. Sorry for late reply above. Press on.